Working ProgramStrategy for the collaboration in the prevention

1 CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) Working Program/Strategy for the collaboration in the prevention of HIV within the context of Northern Dimension Summary HIV-infections spread within the region of Northern Dimension more rapidly than anywhere else in Europe. The extent of the epidemic has a potential to pose a threat not only to public health but also to social stability, economic performance and national security. Yet, examples from several European countries, not least several countries in the Baltic region, show that keeping prevalence and incidence at a low level is possible. Furthermore, recent development in antiretroviral drug therapy provides a new means to our arsenal against the epidemic. Its wide, non-discriminating and well-controlled implementation might have a major impact in the further development of the epidemic. HIV/AIDS is a communicable disease, which spreads by the transmission of a virus. However, the extent of risk behavior and the efficacy of prevention measures heavily depend on political and social factors. Drug users play a key role for the course of the epidemic in the North Eastern Europe and, without prevention of the infection among them and their partners, further rapid spread of the epidemic cannot be avoided. Prevention of HIV among intravenous drug users (IDU) is technically feasible, but politically often very difficult, because IDU as a social group is socially marginalized, discriminated against and criminalized. HIV related risk behaviors are also often aggravated by poverty and ignorance. In this paper experience from the work that has been accumulated within the HIV/STI working group of the Task Force of the Council of Baltic Sea States (CBSS), established to tackle the rapid spread of HIV within the region, has been processed to recommendations that are applicable within the Northern Dimension initiative. The document sets priorities for activities, and is intended to create political advocacy and coordination. Networks operating under the umbrella of the task force provide a useful basis for further activities. The recommendations deal with activities/actions where international collaboration in the context of Northern Dimension is feasible and able to achieve European added value. In order to turn the course of the epidemic in the region, a comprehensive, well resourced and multisectoral approach is necessary requiring national and international inputs. The recommendations cover surveillance, policy implications, development of legislation, prevention, treatment, care and support. Finally, two examples of networks created under the CBSS Task Force are given that could be multiplied into new sites for implementation. Background. Until 1994, countries in this region had few reported HIV infections, most of them attributable to men having sex with men. Situation started to change in 1996, when outbreaks related to intravenous drug use were registered in Kaliningrad and other parts of the Russian Federation. By 2001 the region had - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 2 reported the world’s highest annual growth rates of new HIV cases. According to UNAIDS estimates, HIV prevalence rates in Estonia and Russia, at the end of 2001, were close to 1 percent of the adult population. Specific features include strong association with injecting drug use and, in the Baltic states, also with ethnic background. There are indications that recent trends of increased heterosexual transmissions are consequences of the virus spreading among the sexual partners of injecting drug users (IDU). Social factors drive the use of drugs and the spread of HIV. Marginalisation, discrimination and poverty are obstacles to effective prevention aggravated by the lack of political will to commit sufficient financial and human resources for the work. If the spread of the infection among IDUs cannot be reduced, the epidemic will not be stopped. The Task Force set by the Council of the Baltic Sea States established an HIV/STI network of health care professionals and institutions within the Baltic Sea region to fight against the spread of HIV in the region. A number of collaborative projects were established according to commonly agreed prioritization criteria. Implementation of national policies and strengthening of national structures ranked often high when evaluating applications for new projects. In the future, new activities should, ideally, be built on similar principles and on the established networks. Also the technical support, such as maintenance of data bases, should continue to facilitate the process of project development and funding. However, a wider and more comprehensive approach is needed in order to respond to the worsening situation in the region. Political advocacy and sufficient resources are essential for progress. Legal obstacles for prevention should be removed. Public awareness about the disease should be sharpened and adverse effects of discrimination and the societal roots of the epidemic highlighted to the public. Society should be mobilized not only through NGO:s but also by promoting social cohesion. Health care should be supplied with adequate resources to provide treatment and care, with the special challenge of universal and nondiscriminatory access to antiretroviral treatment. Social rehabilitation should be able to return people with HIV and, often, other signs of risks, to become full members of the society. Dissemination of profound, balanced and up-to-date information on the various issues of HIV-infection is necessary to meet these challenges. The Northern Dimension initiative should bring together highly affected EU countries like the Baltic countries, the less affected neighboring countries like the Northern countries and Russia with its North-Western region in particular, to create a sufficiently powerful pool of political will, knowledge and resources to meet the challenges and turn back the threatening HIV-epidemic in North-Western Europe. Objectives 1. To set the priorities for action 2. To support political advocacy so that comprehensive and effective policies to control the HIV epidemic becomes possible 3. To enhance coordinated and effective collaborative actions for the prevention of HIV AIDS within the region 4. To promote networks and strategies that have been shown to be effective in pilot projects or other areas in the region Current status and trends in the epidemiology. The Baltic states Estonia, Latvia and Lithuania, are the only countries from the ex-Soviet Union to join the European Union (EU), and are among the region’s most developed countries. However, their HIV/AIDS situation, perhaps with the exception of Lithuania, puts them among most problematic - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 3 countries not only in the region but also in the whole of Europe. Estonia, with per-capita GDP measured $10,170 in 2001, reports an HIV prevalence of 1.0 percent and the region’s most rapid growth in HIV incidence (new cases reported) during 2002-2003. Figure 1. Number of new HIV cases reported within the three Baltic countries in 1993-2003. 1600 1474 1400 1200 1000 800 815 842 600 542 458 400 390 397 625 241 200 162 114 0 12 9 8 1994 15 11 1995 20 12 8 1996 31 29 9 1997 52 6 1998 Estonia 66 12 1999 Latvia 65 2000 Lithuania 72 2001 2002 2003 Source: National AIDS Centres In Estonia, the number of people diagnosed as living with HIV soared from eight in 1996 to 3,400 through June 2003. Most infections are reported in IDUs in Narva, Kohtla -Järve (Ida-Virunmaa) and Tallinn (Harju) among Russian-speaking Estonians. While the HIV incidence rate in Estonia (1070.7 per million population in 2001) is the highest in the WHO European Region, the epidemic remains concentrated among IDUs. During 2001 the infection spread from Narva to other towns of IdaVirumaa and Tallinn (409, 454 and 528 cases accordingly). 80% of new HIV cases have been diagnosed in the age groups of 15-24 years old adolescents and young adults, the youngest being only13 to 14 years old. Studies indicate that the most endangered group are young drug users who have only recently started injecting and share syringes, other drug paraphernalia, or even doses. The situation is somewhat similar in Latvia, with a 0.4 percent prevalence rate in 2001 and a sharp growth in new infections in 2001 followed by decline during 2002- 2003. In 2002, 542 new HIV diagnoses were registered in Latvia. This is a decrease of 33% compared to the number in 2001. Since 1998, the main route of HIV transmission has been intravenous drug use but recently heterosexual transmissions have increased (an increase from 8% in 2001 to 16% in 2003). An important feature is that the proportion of infected females aged 15 to 29 is higher than that of males. The registered HIV prevalence remained low in Lithuania until May 2002 when an outbreak in Alytus prison was identified. 207 samples were found HIV positive. By May 1st, 2003, HIV infection in Lithuania has been diagnosed in 70 females and 695 males. Women account for 9 % of all HIV cases, - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 4 84 percent were attributable to injecting drug use, 8% to heterosexual transmission, and another 8% to male-to-male sex (Table). The overall prevalence and incidence of HIV seems to be lower in Lithuania compared to the other two countries. The reason for this difference is not entirely understood but may reflect larger and earlier investments into HIV prevention and/or different patterns of injecting drug use. HIV prevalence continues to rise in the Russian Federation, and now accounts for approximately 70% of all cases registered in Central and Eastern Europe and Central Asian countries. By the end of 2003, a cumulative total of 263.613 people had been reported with HIV according the Federal AIDS Center, from which 34,564 were registered in 2003, indicating that the epidemic is growing at a fearsome rate. UNAIDS estimates that due to underdiagnosing the actual numbers should be much higher, the true number of HIV infected persons in Russia is estimated to be 1 million. While St. Petersburg is one of the worst affected cities in the Federation, HIV/AIDS cases now are reported from 88 of Russia’s 89 sub-national administrative units. From the 24,000 new infections reported in 2002, 76% were attributable to injecting drug use, 12% to heterosexual contact and 12% are children born to HIVinfected mothers. In North-West Russia the local HIV epidemics show considerable differences. In some administrative regions, the numbers of reported cases have remained low while in others the numbers are growing at alarming speed. Probably, regions like Kaliningrad and the Baltic States provide important into the future of the dynamics of the epidemic in NW Russia. After an explosive start the epidemic becomes stabilized but still new infections occur at an unacceptable high rate, in Kaliningrad about 400-600 new cases per million inhabitants per year with gradual shift to sexual transmissions. The demand for medical care including treatment of opportunistic infections and provision of antiviral therapy is soaring. Different studies from St.Petersburg show that HIV prevalence among IDUs remained low and stable until 1999, rose from 4% in 1998 to 12% in 1999, 19% in 2000 and 36% in 2001. Estimating the true number of injecting drug users and the impact of IDU on the spread of the epidemic is difficult, since the stigmatization and criminalization of drug use prevents accurate data collection. Documented transmission routes of HIV cases by June 2003 in percent Route of transmission Injecting drug use Heterosexual activity Male-to-male sex Children born to HIV-infected mothers Source: (UNDP 2004) Estonia 84 13 3 Latvia 83 11 5 Lithuania 84 8 8 Russian Federation 90 6 0.5 3.5 Many women injecting drugs finance their addiction by taking money for sexual services. Sex work is highly stigmatized and criminalized in the Eastern European countries and ex-Soviet republics. As a result, activities are hidden making the women even more vulnerable to HIV/AIDS. Another vulnerable site for HIV spread is the prison system with its inmates. Increasing numbers of prisoners in all states in the region are IDUs sentenced for drug related crimes. Consequently also the proportion of HIV-infected inmates has increased rapidly. Cohabitation of HIV-infected drug users with carriers of multi drug resistant tuberculosis in a crowded and unhealthy environment provide a - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 5 dangerous combination whose impact both on the long term development of the HIV epidemic and the tuberculosis-situation in the countries is not yet fully known. Viral hepatitis and other blood borne infections spread also easily in the prisons and the inmates and ex-inmates contribute a rapidly growing proportion of the entire public health burden of the populations. Studies in several European countries show that drug addicted prisoners often do inject drugs during their incarceration. This is usually done in situations that favor needle sharing and unhygienic practices. Forced sex is a common practice in prisons. In Latvia, a fifth of the country’s known HIV cases are incarcerated. In Lithuania inmates contribute a vast majority of all HIV cases reported in the country. The Russian Federation with its 875,000 prisoners (611 per 100,000 population) has the world’s second highest incarceration and the number of HIV-infected inmates is more than 30000. There is no way to predict with certainty the time course and extent of the future development of the epidemic in the region. In most western European countries the situation has stabilized after initially large and sudden outbreaks in the late 1980:s and early 1990:s, concomitant with considerable reduction in risk behavior like needle sharing, increased use of methadone maintenance treatment for drug use and a shift from criminalization to medicalization of drug use. A high rate of condom use among commercial sex workers can be achieved by active preventive work implemented by targeted programs. However, even in well-off western countries the rate of infected people may remain at a very high level. The possible economic, social and medical consequences of carrier rates up to 5% of the population should be calculated for adequate preparedness. Recommendations 1. Surveillance Surveillance is a key for adequate response. Information to politicians and lay people about the dynamics of the epidemic as well as the dynamics of the underlying risk factors, and impact of interventions are necessary for making correct decisions . Good surveillance needs access to groups at high risk of infection that are often difficult to reach through traditional surveillance methods. Ideally, surveillance should be linked to preventive interventions that are targeted to drug users, commercial sex workers, migrant populations etc. Signs of suboptimal coverage of populations include the rapidly increasing rate of HIV-positive women giving birth to children in Russia without having had contact with the health care during pregnancy. Underreporting may also become more prevalent as many patients seek treatment in private clinics. Monitoring changes in the risk behavior patterns that are associated with HIV spread will become more and more important indicators for the development of the epidemic. Significant improvements in the surveillance of sexually transmitted infections are also needed in almost all of the countries. In many instances, legal obstacles and discrimination is posing challenges to good surveillance. More extensive use of sentinel surveillance could in many instances provide the missing data and indicate trends. Availability of effective treatment for HIV infection as well as for drug abuse will probably increase the willingness of people to seek for testing and other contacts with health care providers. This will improve the sensitivity of surveillance. Voluntary Counseling and Testing (VCT) is an important instrument whose utilization should be enhanced by applying approaches that promotes reaching of vulnerable groups. One way to do this is through low-threshold service centers (LTC) for drug users and for commercial sex workers. Another way is through technical improved test methods that provide immediate results, so that repeated visits will not be needed to learn the result. Wide use of anti- retroviral treatment (ART) will bring along the problem of monitoring the efficacy and compliance among people receiving medication. This should become part of the basic surveillance of the epidemic. Data collection linked to outreach programs is feasible for secondary surveillance. - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 6 Recommendations for actions/priorities (1, surveillance):    Promote effective VCT with special emphasis on reaching the vulnerable groups. (low threshold centers, outreach studies, anonymous testing, technical improvements) Access to (anonymous) VCT should be ensured for IDU:s, CSW:s and their clients, ethnic minorities, foreign students, migrant populations, adolescents etc. Secondary surveillance according to standards set by UNAIDS and WHO should be promoted to receive information about changes in risk behavior and other, societal exposing factors. 2. General awareness, policy development If the current trend continues, the HIV epidemic in the region will become a serious threat to social and economic development beyond being a public health issue. Population trends are already worrisome suggesting the possibility of a major decline in the population size and significant changes in the population structure. Economic performance and growth may be significantly reduced. The epidemic may also affect national security and destabilize the political development in the region. The World Bank projects at cumulative number of HIV cases in Russia in 2020 of 5.4 million as an “optimistic scenario” and 14.5 million as a “pessimistic scenario”. The corresponding increase in mortality and possible net population loss are projected to be 5 million and 13 million by 2020. The impact will be hardest in Russia’s most affected regions, some of which border EU and the Northern countries. The possible outcomes to the Baltic countries have not yet been analysed in detail. Modeling of the outcome of HIV-epidemic in the Baltic region could be a fruitful field of international collaboration including ND. National policies should recognize the severity of the threat and raise the general political awareness of the situation. Measures to eliminate discrimination and increase solidarity with people living with the infection as well as people who need help because their behaviour puts them at particular risk for the infection are necessary. National policies should also ensure that all people at risk get adequate information about the risks and access to means to avoid it. HIV should also become an issue in all sectors of administration and in all policies in order to create the necessary human and financial resources that are needed to change the course of the epidemic. Recommendations for actions/priorities (2. Policies):     General awareness about the impact of the emerging threat and measures to control the situation on individual and societal level should be promoted. Political leadership at all levels is needed (HIV/AIDS cannot be considered just a health issue). Input and support from other sectors should be promoted for effective planning and implementation of the response Human and financial resources for the fight against HIV should be created both within the national health and other sectors of administration (economy, security, industry etc.), localities and the entire civil society The human rights of people living with HIV/AIDS should be equal to those of non-infected people. People are more vulnerable to the effects of HIV infection when they do not have the respect and support of their community. Discrimination due to sexual orientation, drug abuse, ethnic background etc. is a contributing factor in making people vulnerable to infection because of their behavior. - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 7 3. Development of legislation and policies Legislation should not prevent effective, evidence-based prevention strategies. Rather, the laws should facilitate preventive activities in all population groups including people who are particularly vulnerable to the infection and thus may act as the gate through which the virus enters the general population. Legislation should also promote the participation of the entire civil society in the fight against HIV. Preventive work is much more effective if the governmental bodies get full support from civil organisations (NGOs) and self help groups including people with the infection. In some countries recruitment of entire local civil society has been successful in creating a system, which gives support to those affected and supports long-term preventive measures such as reduction of drug abuse and elimination of social exclusion. Private business might have a significant role by reaching their employees in situations useful for preventive interventions. Overwhelming evidence from scientific studies support the view that harm reduction applied to vulnerable groups such as injecting drug users is effective in decreasing HIV incidence rates. Legislation should not prohibit harm reduction applied to vulnerable groups such as injecting drug users, prisoners etc. Legislation could, however become a tool in the fight against discrimination. It should ensure access to free, voluntary, anonymous or confidential HIV/AIDS counseling and testing, and nondiscriminatory access to treatment and care. It should promote the rights of prisoners to receive the same quality health care as the rest of the population. Legislation should also ensure necessary education concerning prevention of sexually transmitted diseases and infections linked with drug use at all levels of education Recommendations for actions/priorities (3. Legislation and policies):      Develop policies to promote partnership between NGO:s, civil societies, private business and governmental agencies in their fight against HIV. This process could be assisted by common, international projects, training etc. Develop policies and legislation to facilitate collaboration in intervention activities involving governmental agencies and civil society targeted to vulnerable groups such as drug users, youth, marginalized populations etc. Develop policies to promote equal, effective and nondiscriminating VTC for everybody. Develop policies to ensure universal, nondiscriminating access to anti-retroviral drug treatment to all infected people, based on medically justified parameters. Develop legislation to allow implementation of evidence-based prevention strategies among vulnerable groups such as drug users, other socially excluded groups, sexual minorities etc. The policies should combine harm reduction programs with medical and social rehabilitation. 4. Prevention HIV-prevention must be a joint effort shared by various sectors of administration such as education, health, justice, economy, defense and internal security. Administration is responsible for successful recruitment of NGO:s and the civil society to work side by side with public bodies. Countries need to scale-up their national HIV/AIDS prevention efforts to allow much broader coverage of at risk populations and other preventive measures to stop the epidemic. A large body of research exists that supports the selection of appropriate preventive strategies. Targeted interventions are necessary to initiate behavioral changes and diminish the transmission risks. Behavior change communication (BCC) can play a vital role in this process. A comprehensive HIV program needs to contain a combination of prevention, care and support, community mobilization and political support. The BCC component can link these elements together. The messages to be conveyed - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 8 and behavioral skills to be learned require devoted people who can be recruited only by including civil society and initiating community wide actions. Involvement of members from the target population is essential. The ability to reach the target populations should be monitored carefully; it may take some time before an intervention becomes sufficiently accepted by the target population to achieve its goal. Basic education at schools should give sufficient information and life skills to average children to be able to avoid HIV-infection. This means that the curricula at schools should be re-evaluated and restructured, also teachers need training to be able to communicate the necessary messages effectively. HIV must be integrated into a broader sexual health agenda. Young people themselves should participate in designing and delivering educational activities. A big challenge is to reach young people who are particularly vulnerable to HIV for various reasons. Prevention of other sexually and parenterally transmissible diseases should be closely linked to HIV prevention. STI control projects should be able to reduce the rate of new infections in particular among young people. Several minority groups are often left outside proper information concerning HIV. This may be due to language problems but also to social marginalization. The status and needs should be investigated and appropriate intervention programs developed. Representatives of target populations should participate in the planning and deliverance of interventions. Reduction of mother-to child transmission (MTCT) to very low levels is possible today with the help of available new medicines. All infected pregnant women should have the option of receiving ART free of charge to prevent MTCT and to keep the mother alive and healthy to be able to support her child. This should be integrated into comprehensive and non-discriminating antenatal services as well as into the social and economic support which young and otherwise vulnerable mothers may need to care for themselves and their child. HIV infected women have the right to take reproductive choices like other women as well. Projects to develop best practices and proper surveillance of this particular problem should be encouraged. Overcrowded prisons with infected inmates and poor hygiene and sanitation are a dominant threat in the field of communicable diseases in the region. Hierarchic gang systems are often the rule in prisons and violence and rape occur frequently. The risk of HIV is higher in prisons than in the general population. At the same time prisons might be a unique site for successful preventive work both for HIV and for drug abuse. HIV testing should be made readily accessible to inmates of all prisons, discretely and at their own request; it should always be voluntary and accompanied by counseling also in the case of negative test results. Needle exchange programs can be useful and integral parts of a general approach to drug and health services in prisons. They should be integrated into other health promotion measures, counseling and social rehabilitation. Cohabitation of HIV-infected people who have varying levels of functional immune deficiencies with people with MDRTB is potentially very dangerous. Also, viral hepatitis is known to be more common in prisons than in the general population. Prevention and treatment of these diseases within the prison institution should be improved and the status carefully monitored. Continuation of preventive work and support after the inmates return to the civil society must be properly organised. This has become even more important with the introduction of ART but also treatment of Tb must continue to avoid the emergence of drug resistant strains. - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 9 Recommendations for actions/priorities (4. prevention):      Promote networks of low-threshold centers for hard-to-reach target groups. Established networks should continue and develop best practice documents. Links with medical and social rehabilitation should be strengthened. “Youth clinics” supporting the development of important life skills to lessen the vulnerability of young people to HIV should be established. Work towards the acceptance of school education programs, with the main aim to increase knowledge, encourage healthy attitudes, develop essential life skills and support non-risktaking behavior. Create networks to improve life skills of young people. Prisons need special attention. To support HIV-prevention, harm reduction strategies need to be implemented, involving all relevant individuals and groups in their design, planning and implementation. Pilot projects for needle/syringe distribution/ exchange should be established. Prevent mother-to-child transmissions. Health services that serve women of reproductive age should be strengthened and reshaped to enhance non-discriminating detection and treatment of HIV-infection during pregnancy. Specific approaches are needed to reach pregnant women with drug dependence. Promote frequent and interactive evaluations of current interventions. Peer reviewing with an international expert base could be an important tool to be applied within the ND. This process would also facilitate networking process.  5. Treatment, care and support Treatment of HIV/AIDS with anti-retroviral drugs has until recently been regarded as impossible in countries with limited resources, because of the drug costs. However, the production of generic drugs, new interpretation of intellectual property rights for lifesaving drugs and development of simplified regimens implying fewer tablets and fewer side effects, has made the introduction of adequate treatment possible in most countries worldwide. Thus, in 2002, WHO issued guidelines outlining the possibility for "Scaling up anti-retroviral therapy in resource-limited settings". More recently the "3 by 5" initiative, in order to make new anti-retroviral drugs available for 3 million HIV-infected persons in need for treatment by the year 2005, the Clinton initiative and US president Bush’s PEPFAR initiative have followed. Widespread unregulated access to anti-retroviral drugs could lead to rapid emergence and spread of resistant strains. Experience from the use of single or double drug regimens have shown how quickly such resistance arose. However, the 3-4 drug combinations of modern HAART (partly available as fixed combinations) have not resulted in a similar development or resistance. Moreover, a minimum of follow-up related to possible side effects of the drugs must be organized, so that the full benefit of dose and drug adjustments can be achieved. This is also necessary to ensure acceptance of drug treatment among the HIV positive people. Anti-retroviral drugs must therefore be provided within a structured framework under government responsibility if full benefits to the patients are to be realized and drug resistance minimized. Anti-retroviral treatment has the promise to significantly enhance HIV prevention but it may also fail. Lowering the price for medicines, technical improvements for simpler dosage and development of new antiviral drugs through research are all necessary ingredients for (near future) success. But the most fundamental prerequisite of all is a universal and non-discriminating access to treatment. The delivery of treatment must be organized in such a way that failures are not common and drug resistant strains may not evolve. This is a challenge since the resources that are needed may exceed the resources that are available for the treatment of some other diseases with big public health importance. Primary health care must be strengthened through training and resources to be able to take care of ART. - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 10 Compliance must be achieved, if necessary, by similar arrangements as are used for DOTS for tuberculosis. Education of health care workers (HCW) in counselling and care of HIV infected people and AIDS patients, is of mandatory importance. Well-informed HCW will help disseminate information and an anti-discriminatory approach into the society. Every contact with the health care services provides an opportunity for counselling that must not be missed. Recommendations for actions/priorities (5. Treatment and care):  Create national treatment guidelines based on scientific evidence. This requires strong educational support from professionals to professionals to exchange experience and develop measures further. To follow treatment schedules adequately, drug users may need support like detoxification, psychological rehabilitation or substitution with drugs like methadone or subutex. A network of common training seminars should be developed to improve skills of the clinicians to deliver and monitor the treatment  Develop a network of diagnostic laboratories to enable monitoring of desease progression, evaluation of treatment success and resistance testing in case of treatment failure.  Strengthen NGOs and communities in their role in supporting home-based care and clinical management of infected persons.  Establish and develop effective education of HCW in counseling and care of HIV-infected people and AIDS patients Networks/Projects created during the CBSS Task force could be used and extended within the context of ND The ND Partnership Declaration states that implementation should be based on the existing international activities in the region. The TF/CBSS was noted as one on the best examples of such collaboration in the field of communicable diseases in the Northern Dimension region. Currently there are 40 projects implemented in the field of HIV/AIDS under the TF initiative. Outside formal projects numerous personal and institutional contacts have been created that form a valuable basis for further development of collaboration. The implementation of ND partnership should be built on the experience gained and networks built. This would bring added value by allowing continuation of existing activities and preventing initiation of overlapping activities. Also, certain projects have proven particularly useful and their duplication in new areas/countries could be promoted. Examples of two such projects are briefly described below: 1. A network of low-treshold-service-centers (LTSC) for drug users in Latvia. Latvian Ministry of Welfare with the financial assistance of the Baltic Sea Task Force on Communicable Disease and UNDP Latvia, as well as contributions from municipalities involved, implemented a 2 year program (2002 – 2003) in 10 municipalities in Latvia. The cornerstones of the program were the harm reduction approach (syringe/needle exchange and counseling/referral), locally based low threshold services including outreach work, state-municipal partnership and a uniform methodology of epidemiological data gathering. Major outcomes include:   The local Centers have been able to reach the previously hidden populations (mainly through outreach work), and increased the number of services provided throughout the course of the project. Counseling increased and improved markedly, indicating that the LTCs indeed filled an important gap in the existing services. Local experts consider that the LTCs are now reaching from “less than half” to “most” IDUs - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) - 11   LTCs have become a valuable addition to the municipal services, which explains the basis for the sustainability of the project effort. A unique system of uniform first-hand data gathering was introduced through LTCs, which forms the basis for epidemiological monitoring of the situation, as well as research. 2. A prison project in Estonia. As a consequence of the extensive outbreak of HIV among IDU:s in Estonia the situation in the prisons changed very rapidly. The aim of the project was to establish a system where all prisoners in Estonia will be offered voluntary and confidential counselling and testing and the inmates will receive relevant information about HIV in Estonian or Russian language. Those who are found HIV positive will receive medical care and treatment in prison and are supported to prevent further spread. Major outcomes include:     VCT services are established in 8 prisons in Estonia Training prison officers and prison staff, as well as HIV counsellor and medical staff in all prisons in Estonia is organized. HIV test kits and necessary equipment to all prisons are procured and distributed. An external quality control by the State Reference Laboratory of HIV/AIDS to monitor the performance of the test kits and the training of the staff in the prisons who use the kits. Acknowledgements: The authors want to thank the members of the CBSS TF HIV/STI working group for active input and comments when this paper was produced ( Pauli Leinikki, Zaza Tsereteli, Ulrich Marcus, Andris Ferdats, Saulius Chaplinskas, Svein Gunnar Gundersen Ingegerd Kallings Aliona Kurbatova, Anna Marzec-Boguslavska, Tatyana Smolskaya) An important source for details and structure used here has been the report of the U.S.-Russia Working Group against HIV/AIDS published by the EastWest Institute, New York 2003 (“On the Frontline of an Epidemic”). - CSR meeting in Stockholm 17 November, 2005. Agenda Item 8 c) -